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Scott & White Health Plan

Provider Forms

Provider Forms

For your convenience, we've provided a list of common forms that you can download any time.

Authorization form - General/Medical/Surgical

Authorization Form - Mental/Behavioral Health

Case Management - Provider Referral Form

Case Management - Facility / Hospital Referral Form

Case Management - Customer Service Referral Form

Designation as Secondary Care Physician for a Health Plan Patient

Eligibility Statement Request Form

Eligibility/Benefits/Claim Status Request Form

Formulary Addition Request Form

Medicare Part D Coverage Determination Request Form

Medications Requiring Prior Authorization Request Form

MyPlan Web Provider Module Sign On Request Form

Provider Appeal Request Form

Provider Data Sheet

Provider Data Update Form

Provider Status Change Form

Specialty Drug Request Form

SWHP S&W System Providers Technical Assessment Form

SWHP Non-S&W System Providers Technical Assessment Form

Texas Standardized Credentialing Application